502.10E1 - Harassment Complaint Form

Name of complainant:                                                                    

 

Position of complainant:                                                                

 

Date of complaint:                                                                      

 

Name of alleged harasser:                                                               

 

Date and place of incident or incidents:                                                

                                                                                        

 

Description of misconduct:                                                              

                                                                                        

                                                                                        

 

Name of witnesses (if any):                                                             

                                                                                        

                                                                                        

 

Evidence of harassment, i.e., letters, photos, etc. (attach evidence if possible):                                  

                                                                                        

 

Any other information:                                                                  

                                                                                        

                                                                                        

 

I agree that all of the information on this form is accurate and true to the best of my knowledge.

 

 

Signature:  ___________________________________________                Date:                

 

 

Approved    4/11/05                        
Reviewed  11/15/21                                                                    
Revised